NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 3 of 3

Pharmacologic Agents and Mental Illness Psychotherapeutic drug agents Symptomatic treatment Psychotropic drugs Effects on neurotransmitters Lipid-solubility of brain barrier

Classification of Drug Agents Psychotherapeutic drug agents Antianxiety agents Antidepressants Antimanic agents Antipsychotic agents Antiparkinson (anticholinergic) agents

Drug-Related Information for the Nurse Psychotherapeutic drug agents Desired therapeutic effect Side effects Adverse effects Normal dosage ranges Indications for use/contraindications Nursing diagnoses Nursing interventions Client/family teaching Outcome evaluation

Antianxiety (Anxiolytic) Agents Psychotherapeutic drug agents Indications for use Anxiety and anxiety disorders Acute alcohol withdrawal Skeletal muscle spasms Convulsive and seizure disorders Status epilepticus Preoperative sedation

Therapeutic Antianxiety Agents Psychotherapeutic drug agents Antihistamines Benzodiazepines Beta-Adrenergic Blockers Miscellaneous

Antidepressants Psychotherapeutic drug agents Indications for use Major depression Dysthymic and bipolar disorders Childhood disorders Obsessive-compulsive disorders ADHD Panic disorder Chronic pain Associated organic diseases

Antidepressant Drug Agents Psychotherapeutic drug agents Tricyclic antidepressants Heterocyclics Serotonin-specific Reuptake Inhibitors (SSRIs) Nonselective Reuptake Inhibitors Monoamine Oxidase Inhibitors (MAOIs)

Mood Stabilizing Drug Agents Psychotherapeutic drug agents Indications for use Manic episodes associated with bipolar disorders Bipolar maintenance therapy Migraine headaches Schizoaffective disorders

Mood Stabilizing Drug Agents Psychotherapeutic drug agents Antimanic Lithium carbonate Anticonvulsants Calcium-channel blocker

Antipsychotic Agents Psychotherapeutic drug agents Indications for use Acute and chronic psychosis Mania Dementia-induced psychosis Intractable hiccups Control of tics and vocal disturbances Adverse reactions and side effects Anticholinergic effects Extrapyramidal side effects

Life Span Mental Health Issues

Family Systems Understanding impact of present and past family patterns of behavior on the choices we make Can lead to intentional desire to make changes and refusal to continue cycle

Family Systems Nuclear family of origin Includes family history/relationships Single emotional unit of relationships that intermingle over generations Family Dynamics – key to understanding current behaviors Tend to seek partners of similar differentiation

Family Systems: Healthy Clear generational lines Strong parental coalition Maintenance of marital relationship Communication is clear, honest, direct, specific and congruent Roles clear and not defined by gender Rules defined and respected Okay to express ideas that differ Differences accepted

Family Systems: Healthy Empathy, warmth & caring expressed Feelings addressed Level of conflict low and resolved High self-esteem Parents make decisions Healthy lifestyle Regular exercise & recreation Absence of dangerous activities No significant deviance in school or work performance, or in relationships with others

Family Systems: Troubled Strive to do well Boundaries appear clear, but when under pressure Turn inward (rigid) or Problems spill into the environment (disordered, diffuse) Links to society may be mistrustful, with limited input from larger society Children learn power through manipulation rather than learning responsibility

Family Systems: Troubled Power may be diffuse and may not come from parents Little empathy shown Conflict over rules & family norms Caring is controlling rather than growth producing Self-esteem low

Family Systems: Troubled (continued) Parental coalition present, but weak and ineffective Parents may reach across generational boundaries for comfort and support “Triangled” often symptom bearer Overt or covert incestuous situations may be present

Family Systems: Troubled (continued) Communication: May not be clear, honest or specific Expressed with fear, guilt or anger Incongruence between verbal and nonverbal Disqualification through silence, ignoring, evasiveness or changing subject Excessive use of alcohol, nonprescription and Rx drugs Eventual dysfunction of one or more family members

Family System and Children Children are affected by family relationships Marital conflict Fighting Siblings Boundaries Parental psychopathology Separation/loss: death, divorce, absent parent

Family Psychoeducation Focus on education & support Works best with family & client with major mental illness Techniques Communication training Problem solving Goals: Improve course of the family member’s illness  relapse rates  client and family functioning Goals achieved through: Educating family about mental illness Teaching families techniques to cope Reinforcing family strengths

Commonalities of Family Theories Individual symptoms understood in context of family system Facilitate interaction & communication among family members Family members directed to modify patterns of their relationships

Disorders of Infants, Children and Adolescents

Etiologic Factors Etiology Genetic Environmental Parental divorce (1st degree biological relative with disorder or family history of mental issues) Environmental Socioeconomic – neighborhood Family income Educational level of family members Parental divorce Combined factors

Infancy: Attachment Theory Suggests most significant affectional bond between parent and child Essential for healthy emotional development Disruption Parental mental disorder, chemical dependence, absence Attachment experiences shape circuitry of brain Faulty circuitry leaves child vulnerable to later emotional dysregulation Disruption correlated with development of psych disorders

Infancy: Eating Disorders Pica: Eating 1 or more non-nutritive substances for at least 1 month and inappropriate for developmental level Frequently associated with mental retardation (MR) and pervasive development disorder (PDD) Infancy Feeding Disorder Persistent failure to eat adequately Significant failure to gain weight or weight loss for at least 1 month R/0 medical condition Temperamental characteristics and parental psychopathology, child abuse/neglect

Anxiety Disorders Anxiety disorders Separation Anxiety Disorder - Developmentally inappropriate excessive anxiety over separation from home/attachment figures Worry about harm to self/parent Fear of sleep without attachment person present Attention-demanding behavior Tic Disorders Rapid, rhythmic, involuntary movements or vocalizations Symptoms accentuated with stress, excitement & fatigue Tourette's Syndrome: Worst. Haloperidol (haldol)

Elimination Disorders Enuresis: Bed wetting > 5 years old, 2x/ week for 3 consecutive months Encopresis: Stool in inappropriate places, voluntary or involuntary: 1 incident per month for > 3 months

Communication Disorders Variation in voice, rhythm or articulation Impairments in: Language expression (limited vocabulary, errors in tense, difficulty recalling words or producing sentences with dev. appropriate length) Understanding language (i.e., words) Phonology (speech & sound production) Stuttering (sound & syllable repetition, sound prolongation, etc.) Evidence for a genetic factor

Pervasive Developmental Disorders (PDD) Due to a mental and/or physical impairment (or combination) Diagnosed before age 22, 60% co-existing psychiatric disorder Functional limitations (in 3 areas): Self-care Language Learning Self-direction Mobility Independent living Economic self-sufficiency May have average or above average IQ e.g., autistic disorder, down syndrome, seizure disorder

PDD: Autistic Disorder Onset < 2.5 years 75% retarded Repetitive behavior: rocking, twisting Upset over changes in routine Poor coordination Impaired communication Lack emotional responsiveness & social reciprocity Fail to develop interpersonal skills

Mental Retardation (MR) Diagnosed < age 18. Mild to profound Sub-average intellectual functioning (IQ 70 or below) Limitations in 2 or more adaptive skill areas: Self-care Communication Home living Self-direction Social skills Community use Academics Leisure, work Health & safety

Disorders of Childhood Motor Skills Disorder Motor coordination below expected for age and measured intelligence Learning Disorders Reading, math or writing skills below that expected for age, schooling, level of intelligence

Behavior Disorders Attention Deficit/Hyperactivity Disorder Dx’d under age 7 w/ > 6 months duration, more frequent in males Problems paying attention & concentrating and/or with hyperactive & impulsive behavior Unable to listen well, organize work and follow directions Risk failing at school 1/3 substance-abuse problems Often continues into adulthood  blood flow & lower levels of electrical activity - requires more stimulation to feel optimally aroused

Behavior Disorders: ADHD Tx Ritalin (methylphenidate) drug of choice Stimulant s availability of norepinephrine Helps adults/children  concentration Other stimulant drugs: Adderall (amphetamine mixture), Concerta (long acting Ritalin), Dexedrine, Cylert New route of delivery - patch (good for those with difficulty swallowing, remove after school) At risk for stunted bone growth,  BP  concern about abuse potential 70% respond to stimulants Antidepressants may help

Behavior Disorders: ADD/ADHD Teaching points for ADD/ADHD Set clear limits for behavior Give positive reinforcement for desired behavior Give time out for undesired behavior Provide feedback as soon as possible after behavior Consistent approach from both parents Keep instructions simple Ask child to repeat instructions Set realistic goals for child’s behavior

Behavior Disorders: ADD/ADHD Stimulant Medication–teaching points for parents Assess for decreased appetite, weight loss, growth delays, abuse Prevent insomnia–give no later than 6 hours before bedtime Do not stop medication abruptly Give at mealtimes if weight loss; offer with favorite foods

Behavior Disorders Oppositional Defiant Disorder (ODD) Negative, defiant, disobedient, hostile Argues incessantly without compromise Defiant refusal to obey rules or laws Vindictive, spiteful and resentful Suspension and expulsion from school Conduct Disorder (CD) Disruptive, destructive behavior, rules violated, deceitful, willful defiance, aggression, truancy, cruelty to animals and people, impairment in social, academic or occupational functioning ADHD ODD CD APD

Childhood Disorders Many disorders not diagnosed until adulthood Substance abuse: Early use (by age 11) predicts more sustained use Depressive disorders: Adolescents express in acting out behaviors to hide vulnerability Bipolar disorders: Sleep disruption, energetic, grandiosity, poor judgment Thought disorders: Hallucinations and delusions less detailed, delays in speech development, poor eating and sleeping habits High rate of co-occurring disorders

A. Highly creative, imaginative play B. Early development of language The nurse is providing community education about autism to a group of parents. The nurse concludes that teaching has been effective if the parents describe which of the following as common behavioral signs of autism? A. Highly creative, imaginative play B. Early development of language C. Overly affectionate behavior toward parents D. Indifference to being held or hugged D. Indifference to being held or hugged

The parent of a child with attention-deficit/hyperactivity disorder (ADHD) tells the nurse that the child doesn’t follow instructions well. Which strategy should the nurse recommend to the parent? A. “Teach your child to be less aggressive and more assertive.” B. “Consider developing a predictable daily routine.” C. “It could be helpful to assign time out if instructions aren’t followed.” D. “Try having your child repeat what was said before starting the task.” D. “Try having your child repeat what was said before starting the task.”

A. Amitriptyline (Elavil) B. Paroxetine (Paxil) A 3-year-old client has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The child’s parents report that a friend told them that the child will likely receive “lots of drugs.” The nurse should reply that the child will most likely be given a drug such as: A. Amitriptyline (Elavil) B. Paroxetine (Paxil) C. Amphetamine and dextroamphetamine (Adderal) D. Haloperidol (Haldol) C. Amphetamine and dextroamphetamine (Adderal)

A 13-year-old child is brought to the clinic with a history of a conduct disorder. The nursing history reveals several facts about the family. Which one is most likely to have contributed to the child’s conduct problems? The parents: A. Have very high expectations of the child B. Employ harsh discipline and inconsistent limit- setting C. Are excessively involved in the everyday life of the child D. Have no other children B. Employ harsh discipline and inconsistent limit-setting

Which primary interventions should the nurse plan for when a child has a conduct disorder and is impulsive and aggressive? A. Limit setting and consistency B. Open communications and a flexible approach C. Open expression of feelings D. Assertiveness training A. Limit setting and consistency

Life Span Mental Health Issues Effect of mental illness on child achieving developmental tasks: May have increased difficulty of achievement May be stuck in stage at onset of illness May never achieve developmental task Can benefit from nursing interventions

Life Span Mental Health Issues Helping a child with mental illness master developmental tasks: Assess child’s behaviors related to developmental task Provide the child with normalizing experiences Allow to choose age-appropriate play activities Reinforcement for age-appropriate behaviors Healthy, pleasant environment Promote coping skills (decision making, stress reduction, problem solving)

Life Span Mental Health Issues Interventions for increasing resilience in children at risk for disruptive behaviors: Provide a supportive relationship with community member Provide a positive environment at home at school in community

Interventions: Play Therapy Commonly used with children Purposeful use of toys and other equipment Helps to communicate perceptions of the world and to help master the environment  self-esteem Enhances problem solving Gains perspective on traumatic event

Interventions: Pharmacotherapy Prozac – the only antidepressant approved for children by FDA. Paxil, Zoloft, Celexa and Effexor considered unsafe and ineffective for most children and dangerous with suicidal tendencies Risk sudden of death on tricyclic antidepressants (TCAs). Request baseline EKG, repeated when TCA ; blood levels useful in confirming compliance. Lab tests for anemia and thyroid function needed Meds metabolized more efficiently so milligram/kilogram base is used rather than a certain dose Initial doses may be low, but can ultimately be as high as for adults

Childhood Interventions Family therapy 1:1 therapy Play therapy Case management Behavior modification Parent effectiveness training School and community interventions Parental involvement a key component of achieving successful outcomes

A. Act out feelings in a constructive manner The nurse employs play therapy with a small group of 6-year-old clients. The primary expected outcome is for the clients to do which of the following? A. Act out feelings in a constructive manner B. Learn to talk openly about themselves C. Learn how to give and receive feedback D. Learn how to play A. Act out feelings in a constructive manner

Therapeutic Issues of Adolescents Identity formation Independence vs. rebellion Social role Acting out behaviors Coordinate self-security, intimacy and sexual satisfaction

Depression & Suicide Adolescent depression symptoms Masked via behavioral problems such as poor school performance and acting out at school Protects adolescent from appearing vulnerable and dependent Suicide is 3rd leading cause of death in 15-24 year olds

The nurse is conducting a community education session about preventing deaths in adolescents. Place in order from most frequent to least frequent the causes of preventable adolescent deaths that the nurse needs to include in the presentation. a. Accidents b. AIDS c. Homicide d. Suicide 1, 3, 4, 2

A. Similar in presentation to depression in adult clients When assessing an adolescent client for depression, it is most important for the nurse to recognize that depression in adolescents is often: A. Similar in presentation to depression in adult clients B. Masked by aggressive behavior C. Situational and not as serious as depression in adults D. An indication of family dysfunction B. Masked by aggressive behavior

Life Span Mental Health Issues Adolescent Eating Disorders Anorexia nervosa is characterized by refusal to maintain minimally normal weight. Bulimia nervosa is characterized by repeated episodes of binge eating followed by purging behaviors.

Life Span Mental Health Issues Anorexia Nervosa Maintenance of subnormal body weight for age/ height (<15%) Although underweight, individual has intense fear of becoming fat. Weight loss self-imposed Body image disturbance (self-image related to food) Obsessive preoccupation with food Denial of wt. loss, thinness and potential health hazards Develops symptoms of starvation Lack of sense of control or competence in any area of life besides weight control. Treatment goal is to restore healthy eating patterns and reverse physiological damage

The nurse is teaching a group of young adolescents about eating disorders. The nurse would consider the sessions effective if the participants state that anorexia nervosa is best defined as an eating disorder that occurs: 1. Only in young girls who are depressed 2. Mainly in young girls who perceive themselves to be grossly overweight 3. Primarily in young girls who live in chaotic families 4. In young boys and girls alike 2. Mainly in young girls who perceive themselves to be grossly overweight

The school nurse is conducting an assessment to determine if a client has anorexia nervosa. Which statement(s) by the client most suggest that the client may indeed have anorexia nervosa? Select all that apply. A. “I don’t have periods anymore. I’m glad.” B. “People say I’m skinny, but I’m fat and repulsive.” C. “The idea of eating makes me nauseated.” D. “I know that I have a problem with eating.” A, B, C

In order to be admitted to an inpatient treatment program, clients with anorexia nervosa must meet the admission criterion of having experienced at least a 30% weight loss over the immediate past 6 months. The client currently weighs 84 pounds. The nurse calculates that 6 months ago, this client weighed at least _____pounds. 120

Life Span Mental Health Issues Bulimia Nervosa Binge eating with inability to stop (many calories) Anxiety often triggers binge Craving for high calorie/sweet food Shame, 75% depressive symptoms Secretive eating/stashing of food Depression Negative self-image Purging: Induced vomiting, laxative/diuretic/enema use Normal height/weight with little variation Associated anxiety/personality disorder Fasting and/or excessive exercise Electrolyte imbalance, irregular HR The priority is to maintain client safety and stabilize physiologic problems (e.g., dehydration, electrolyte imbalance, arrhythmia).

Life Span Mental Health Issues Eating Disorder Not Otherwise Specified (NOS): Binge Eating and Obesity One-third in U. S. obese 20%> ideal weight Compensation for love & nurturing Defensive against intimacy with opposite sex R/O medical: hypothalamus or thyroid dysfunction Ridiculed by peers, may be excluded - can affect self-esteem

Eating Disorders NOS (continued) Causes Societal (TV, junk food), overweight parents with poor health habits, frequent eating out Genetic - Identical twins reared apart are similar in body shape/fat to those reared in the same home (genetics)

Nursing Interventions Interventions with the adolescent Therapeutic alliance Identify feelings and relationship to behavior Reflect on negativism and critical attitudes Identify tendency to view from extremes Encourage catharsis Skillful milieu management of peer group

The nurse is evaluating the progress of an adolescent bulimic client who is being treated as an outpatient. Which behavior would indicate that the client is making positive progress? The client: A. Asks the nurse many details about the nutritional content of foods B. Shows the nurse a completed food and emotion diary C. Reports enjoying spending time alone after meals D. Describes eating at times other than when the family members are eating B Shows the nurse a completed food and emotion diary

A. Rigidly controlling what he or she eats B. Binging and purging The nurse is conducting an in-service education session about the relationship between anxiety and bulimia nervosa. The nurse best describes the relationship by saying, “When a client has bulimia nervosa, an increase in the anxiety level will generally result in: A. Rigidly controlling what he or she eats B. Binging and purging C. Overeating D. Consuming alcohol B, Binging and purging

Life Span Mental Health Issues Older Adult: Assessment Carefully assess older adults to differentiate among dementia, delirium, and depression Assess ability to accomplish physical and instrumental activities of daily living Mental health issues identified earlier continue to manifest in old age Activities of daily living (e.g. shopping, cooking, financial management, etc.)

Life Span Mental Health Issues Older Adult: Interventions Older adults are more prone to the side effects and toxic effects of many medications (at risk populations also include children, pregnant and lactating women). Medications may initially be given at half the normal adult doses and any increases in dosages are made slowly.

Life Span Mental Health Issues Older Adult: Delirium Associated with variety of medical conditions/psychosocial changes Develops quickly compared to dementia Symptoms can fluctuate within 24-hour period Disturbance in consciousness Confusion, anxiety, distractibility, appetite and sleep disturbances May have memory loss, hallucinations, delusions, language disturbances and agitation Temporary condition, if underlying condition treated Memory impairment accompanied by disturbance in consciousness

Life Span Mental Health Issues Older Adult: Delirium Medical conditions Medications Substance toxicity Toxin exposure Combination of factors **Older adults at greater risk (multiple diagnoses and polypharmacy, decreased metabolism and excretion of drugs) Most cases are reversible with treatment Must determine cause – which drives treatment

Life Span Mental Health Issues Older Adult: Dementia Develops gradually; may not be noticed for years First stage: Confusion, such as about directions (navigational) and decisions Second stage: Difficulty recognizing family and friends Third stage: May refuse to do any Activities of Daily Living (ADLs) Symptoms do not fluctuate in 24-hour period May be related to specific medical conditions, such as Parkinson’s disease or HIV Irreversible, progressive cognitive decline including loss of awareness, judgment, ability to reason…severe enough to interfere with daily functioning and communication with others

Life Span Mental Health Issues Older Adult: Dementia Primarily affects: Cerebral cortex (conscious thought and language) Production of acetylcholine (memory and learning) Hippocampus (memory storage) Neurons degenerate and lose synaptic connections to other neurons

Life Span Mental Health Issues Older Adult: Dementia Losses: Ability to do purposeful movement (Apraxia) Inability to acquire and process new information Recent memory – lost first Remote memory – more marked as disease progresses Language: Anomia – inability to find the right word Agnosia – inability to identify an object Aphasia – impairment in the significance or meaning of language (inability to understand what is heard, follow instructions, communicate needs)

Life Span Mental Health Issues Older Adult: Dementia Sundowning – What is it? As the sun goes down those with Alzheimer’s tend to exhibit increased confusion irritability restlessness Cause could relate to decreased light = decreased vision = increased perceptual problems = increased fear

Life Span Mental Health Issues Older Adult: Dementia vs. Delirium vs. other Accurate Diagnosis is important Diagnostic tests Complete psychological evaluation Why? Delirium is reversible Client may have depression or other diagnosis

Life Span Mental Health Issues Older Adult: Dementia vs. Delirium vs. other Safety: Number 1 concern with cognitive disorders Delirium - may wander; have impaired judgment, forget what things are for Dementia - may get lost; in later stages, prone to choking, seizures, infections

Life Span Mental Health Issues Older Adult: Common Interventions for Dementia and Delirium Check on frequently Use alarm devices to warn of wandering Remove harmful items from environment Use respectful manner Place calendar and clock in room Reorient each time staff enter room Others? What others can you think of?

Life Span Mental Health Issues Older Adult: Common Outcomes for Dementia & Delirium Remain free of falls Perform oral and hair care by given period of time Remain in bed, on unit or in facility, whichever is appropriate to client Recall a specific relative by name Alzheimer’s disease: Locate his or her room at least once a day within the following week Increase sleep period at night to ____ hours

Life Span Mental Health Issues Older Adult: Depression No real/sustained memory impairment Non-progressive May accompany early stages of dementia Changes in appetite, sleep patterns Fatigue Withdrawal, self-neglect, helplessness Will not attempt to answer questions Treatable. Responds to treatment – improvement in cognitive ability - medications, therapy, ECT

The client with Alzheimer’s says to the nurse, “I have a date tonight for the Valentine’s dance.” What is the most appropriate response by the nurse? A. “You’re confused again. There isn’t a dance tonight and this isn’t Valentine’s Day.” B. “I didn’t think your spouse was still living. Who is your date with?” C. “I think you need some more medication. I’ll be right back with your shot.” D. “Today is January 11th. Tell me about some of the other dances you’ve been to.” D. “Today is January 11th. Tell me about some of the other dances you’ve been to.”

The nurse is teaching a family caregiver how to help a client with early dementia complete activities of daily living (ADLs). Which information should be included in the teaching? A. Perform the ADLs for the client. B. Have the client plan a schedule for ADLs. C. Give the client ample time to perform the ADLs as independently as possible. D. Tell the client that the ADLs must be finished by 9:00 a.m. C. Give the client ample time to perform the ADLs as independently as possible.

2003 Microsoft Office Clip Art Gallery. Photo Acknowledgement: Unless noted otherwise, all photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.